Health-care expenditure and health policy in the USA versus other high-spending OECD countries
By Luca Lorenzoni MSc, Annalisa Belloni MSc, Franco Sassi PhD
The Lancet, July 1, 2014
Summary
The USA has exceptional levels of health-care expenditure, but growth has slowed dramatically in recent years, amidst major efforts to close the coverage gap with other countries of the Organisation for Economic Co-operation and Development (OECD). We reviewed expenditure trends and key policies since 2000 in the USA and five other high-spending OECD countries (Canada, France, Germany, the Netherlands, and Switzerland). Higher health-sector prices explain much of the difference between the USA and other high-spending countries, and price dynamics are largely responsible for the slowdown in expenditure growth. Other high-spending countries did not face the same coverage challenges, and could draw from a broader set of policies to keep expenditure under control, but expenditure growth was similar to the USA. Tightening Medicare and Medicaid price controls on plans and providers, and leveraging the scale of the public programmes to increase efficiency in financing and care delivery, might prevent a future economic recovery from offsetting the slowdown in health sector prices and expenditure growth.
Health expenditure levels
The higher health spending reported in the USA is not simply a result of the country’s greater wealth or of the age structure of its population. Even the larger prevalence of risk factors — including obesity — explains only a small part of the reported differences. OECD Health Care Quality Indicators show that the US health-care system is doing well in several areas (eg, cancer care), but less well in others (particularly the primary care sector). Overall, the quality of the care provided does not seem to explain the higher health expenditure in the USA.
OECD work on comparative price levels in health suggests that the prices, rather than volumes, of health services contribute the most to explaining the higher US spending, in line with the conclusions of scholarly work.
Probable explanations for health price levels exceeding general price levels in the USA include a more intense use of health-related technologies, low productivity, decentralised price negotiations, fragmentation in the insurance market, and a high level of provider concentration. In a private insurance or provider model — as in the Netherlands and Switzerland (with compulsory insurance coverage), and the USA (with voluntary insurance coverage) — a high amount of choice is combined with weaker cost control. In particular, the USA — excluding Medicare — does not use a centralised authority to set health spending budgets or negotiate prices with providers. A public-contract model — as in Canada, France, and Germany — gives a central authority (national government or social insurance administration) more leverage over health-care providers, generally with lower administrative costs than multiple-payer systems.
From the Discussion
The USA is an outlier in the scenery of OECD health-care systems, for its staggering levels of expenditure, the extent of fragmentation of its system and the sheer complexity of its administration, the power of vested interests, and the large number of people left without adequate health insurance coverage. However, during the period examined in this paper, characterised by a long and severe recession with a fluctuating economy and employment rates, differences in growth rates between the USA and other high-spending countries were substantially reduced. Great efforts have been made to sustain coverage and lift the USA from the bottom of the OECD coverage league table. Efforts have also been made to contain further growth in health-care expenditure, with rates falling in line with those of other high-spending OECD countries. This progress is no reason for complacency, and more and bigger efforts are needed in the years to come, particularly in controlling the main driver of higher health-care expenditure in the USA — ie, health sector prices. The risk that a future sustained economic recovery, and the probable general price increases that would come with it, might offset the gains made in recent years is real and should be anticipated. Medicare and Medicaid price controls on plans and providers, such as adjustments in payments to Medicare Advantage managed care plans, or DRG base rate adjustments to account for expected productivity growth in the general economy, could be tightened further and extended, particularly for pharmaceutical products and physician fees, without resorting to measures affecting service use, which would restrict choice or coverage. More daring measures could be used in the hospital sector, such as all-payer fees negotiated at state level (eg, Maryland’s Health Service Cost Review Commission), global budgets, and reference prices, although these would involve major changes in the US health-care market approach. Examples of effective measures are available from other countries, which might bring the USA further in line, in terms of both health-care expenditure and coverage, notwithstanding the relatively smaller effect of policy changes in the USA, in view of the different relation between insurance or financing and delivery systems. Changes gradually introduced towards the end of the study period, which will probably affect expenditure growth in the future, include bundled payments, reference prices for hospital care, and the introduction of Accountable Care Organisations to realign provider incentives, with a potential for quality improvement, in addition to cost containment. However, more evidence is needed about the complex causal pathways that link health-care expenditure and use with health outcomes, to avoid possible detrimental effects on population health from tightened controls on health-care expenditure.
[The authors are from the Health Division, Organisation for Economic Co-operation and Development (OECD), Paris, France.]
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60571-7/fulltext
Press release – The Lancet: “Dramatic slowdown in growth of US health expenditure over last decade closes gap between USA and other high-spending countries”: http://www.eurekalert.org/pub_releases/2014-06/tl-tld062714.php
Press release – OECD: “After Decline in U.S. Health Expenditure Growth, OECD Sees Risk of Spending Uptick in Recovery”: http://www.oecd.org/washington/lancet-health-unitedstates.htm
Comment:
By Don McCanne, MD
This OECD study comparing health care spending and health policy in the United States with five other high-spending OECD nations confirms that health care financing systems undergo continual revision. Yet the United States is unique in that our policy changes have not moved us from first position on per capita spending nor from last position on the proportion of the population that is covered.
As the authors state, “the USA is an outlier in the scenery of OECD health-care systems, for its staggering levels of expenditure, the extent of fragmentation of its system and the sheer complexity of its administration, the power of vested interests, and the large number of people left without adequate health insurance coverage.” Although some slowing in health care spending has occurred, future spending trends are uncertain.
The authors suggest some possibilities for reform, but they are based on maintaining the basic financing structure that was expanded but not fundamentally altered by the Affordable Care Act (ACA). In fact, some of their suggestions were derived from ACA.
This paper is helpful since it describes the dynamics of health financing policy in several wealthy nations. We can always learn from others, even if the lessons are on what not to do. On the latter point, other nations have had much to learn from us even if they have not applied the lessons well (e.g., unwise attempts at privatization schemes).
The obvious flaw in this paper is that the authors did not discuss more comprehensive reform proposals such as a single payer national health program. They do, however, note that the United States “does not use a centralised authority to set health spending budgets or negotiate prices with providers,” whereas a public-contract model used in other nations “gives a central authority (national government or social insurance administration) more leverage over health-care providers, generally with lower administrative costs than multiple-payer systems.”
Doesn’t it seem that this is the lesson we should be receiving from other nations? Doesn’t this cry out for single payer in the United States? Of course, we already knew that. Our policy failure is a political failure. We will not get the policy right until we change our politics.
